OMB control number

Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats

OMB 0935-0143 · HHS/AHRQ.

OMB 0935-0143

The Patient Safety and Quality Improvement Act of 2005 (hereafter the Patient Safety Act), 42 U.S.C. 299b-21 to 299b-26, was enacted in response to growing concern about patient safety in the United States and the Institute of Medicine's 1999 report, To Err is Human: Building a Safer Health System. The goal of the statute is to improve patient safety by providing an incentive for health care providers to work voluntarily with experts in patient safety to reduce risks and hazards to the safety and quality of patient care. The Patient Safety Act signifies the Federal Government's commitment to fostering a culture of patient safety among health care providers; it offers a mechanism for creating an environment in which the causes of risks and hazards to patient safety can be thoroughly and honestly examined and discussed without fear of penalties and liabilities. It provides for the voluntary formation of Patient Safety Organizations (PSOs) that can collect, aggregate, and analyze confidential information reported voluntarily by health care providers. By analyzing substantial amounts of patient safety event information across multiple institutions, PSOs will be able to identify patterns of failures and propose measures to eliminate or reduce patient safety risks and hazards.

The latest form for Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats expires 2028-07-31 and is listed under ICR 202512-0935-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 8 OCR Complaint Consent FormForm and Instruction
Form 8 Attachment I_OCR Complaint Consent FormForm and Instruction
Form Form 7 PSO Request for Voluntary RelinquishmentForm and Instruction
Form Form 7 Attachment J_PSO Voluntary Relinquishment FormForm and Instruction
Form Form 6 PSO Change of Listing InformationForm and Instruction
Form Form 6 Attachment H_PSO Change of Listing InformationForm and Instruction
Form Form 1 PSO Certification for Initial Listing FormForm and Instruction
Form Form 1 Attachment C_Patient Safety Organization Certification for Initial Listing FormForm and Instruction
Form Form 5 PSO profile nameForm and Instruction
Form Form 5 Attachment G_PSO Profile FormForm and Instruction
Form Form 3 PSO Two Bona Fide Contracts Requirement FormForm and Instruction
Form Form 3 Attachment E_PSO Two Bona Fide Contracts Requirement FormForm and Instruction
Form Form 4 PSO Disclosure StatementForm and Instruction
Form Form 4 Attachment F_PSO Disclosure Statement FormForm and Instruction
Form Form 2 PSO Certification for Continued Listing FormForm and Instruction
Form Form 2 Attachment D_PSO Certification for Continued Listing FormForm and Instruction
Form Form 9 AHRQ Common FormatsForm and Instruction
Form Form 9 Attachment K_AHRQ Common FormatsForm and Instruction
NonSub Change - Update to AHRQ PSO Profile Form.docxJustification for No Material/Nonsubstantive Change
NonSub Change - Update to AHRQ PSO Profile Form.docx Justification for No Material/Nonsubstantive Change
Attachment B_Patient Safety and Quality Improvement Rule-2008.pdfSupplementary Document
Attachment B_Patient Safety and Quality Improvement Rule-2008.pdf Supplementary Document
Attachment A_Patient Safety and Quality Improvement Act of 2005.pdfSupplementary Document
Supporting Statement Part A_PSO Certification and Related Forms 0934-0143.docxSupporting Statement A
Supporting Statement Part A_PSO Certification and Related Forms 0934-0143.docxSupporting Statement A
Attachment I_OCR Complaint Consent Form Form and Instruction
Attachment I_OCR Complaint Consent Form Form and Instruction
Attachment J_PSO Voluntary Relinquishment Form Form and Instruction
Attachment J_PSO Voluntary Relinquishment Form Form and Instruction
Attachment H_PSO Change of Listing Information Form and Instruction
Attachment H_PSO Change of Listing Information Form and Instruction
Attachment C_Patient Safety Organization Certification for Initial Listing Form Form and Instruction
Attachment C_Patient Safety Organization Certification for Initial Listing Form Form and Instruction
Attachment G_PSO Profile Form Form and Instruction
Attachment G_PSO Profile Form Form and Instruction
Attachment E_PSO Two Bona Fide Contracts Requirement Form Form and Instruction
Attachment E_PSO Two Bona Fide Contracts Requirement Form Form and Instruction
Attachment F_PSO Disclosure Statement Form Form and Instruction
Attachment F_PSO Disclosure Statement Form Form and Instruction
Attachment D_PSO Certification for Continued Listing Form Form and Instruction
Attachment D_PSO Certification for Continued Listing Form Form and Instruction
Attachment K_AHRQ Common Formats Form and Instruction
Attachment K_AHRQ Common Formats Form and Instruction

OMB Details

Attachment K_AHRQ Common Formats

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form Form 9AHRQ Common FormatsFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.